UC Berkeley Web Feature

In this interview series, we lunch with not-yet-famous
faculty, learning about their fields and
the paths that led them there. With luck — and
the right sandwich — we get a glimpse
into what makes these Berkeley brains tick.

BERKELEY – In
the United States, being black is dangerous to your
health. Adjusted for age, the African-American death
rate from strokes was 43 percent higher than for
Caucasians, 31 percent higher for heart disease,
and 23 percent higher for cancer, according to the
National Center for Health Statistics. Yet for a
long time, public-health research has treated race
as a "nuisance" variable, one much less
important than factors like income and education
level.

A new
generation of researchers, like Amani Nuru-Jeter,
assistant professor at UC Berkeley's School
of Public Health, is starting to look at the data
from a very different angle. Maybe the important
part is not that rich black corporate lawyers tend
to be as healthy as rich white corporate lawyers,
but that there are so few of the former compared
to the latter. Maybe the variable to look at is
not race, but racism.

"It's not a coincidence that
blacks are overrepresented in low-income groups,
and whites are overrepresented in high-income groups,"
said Nuru-Jeter over a recent
salad at Jupiter. "Rather, the history of racial
discrimination in this country has systematically
placed different racial groups into different levels
of socioeconomic status, or SES, which has persisted
over time. So then, how important is it for us to
ask whether [the culprit is] race or SES? I would
suggest that instead of trying to figure out which
is more important, that we should try to better understand
how the two interact."

In essence, Nuru-Jeter and other public health researchers
like her are at the beginning of trying to answer
a rather controversial question: What
if a person's constant, stress-inducing experiences
with discrimination are more likely to cause poor
health than are the tiny biological differences associated
with skin color?

Flying solo

Nuru-Jeter has often found herself
in situations "where I am the only one of me,
what we call 'solo status,' whether it’s because
of my color, gender, both, or the kind of research
that I do," she shrugs. She first
stood out in the elementary-school cafeteria. For
health reasons, her mother was raising Amani and
her younger sister as vegetarians, which was not
so common in Washington, D.C., at the time.

"Oh,
how we hated it," she recalls. "I
remember I once traded my lunch for a ham sandwich,
and when the other girl found out she'd ended up
with an olive and cream-cheese sandwich, she was
so mad."

The vegetarianism didn't stick, but her religious
upbringing did. Nuru-Jeter's Christianity "is
a big part of who I am as a person," she says. "I
don't think of it as a religion; I just think of
it as how I live my life." The reason why
she's picking at a bare-bones spinach salad while
I chomp down on a big, greasy veggie burger is that
she's gearing up for a 40-day juice fast. "Every
year I like to take time to sacrifice something that
will remind me to go into deeper devotion to God," she
explains. Her hunger pains remind her to pray. "But
don't worry, as a public-health person I know I have
to supplement my diet, to make sure I'm getting all
the protein and other nutrients that I need."

Nuru-Jeter's path to public health started out as
a tangent. She grew up wanting
to be a doctor and was pre-med at the University
of Maryland, majoring in biology and neurophysiology. "I
didn't know what kind of doctor I wanted to be, but
I always wanted to be one," she recalls. "I
had a lot of illness in my family, and I was just
fascinated by the idea of being able to help people
become healthier, stronger, and more vibrant."

'I would suggest that it didn't just happen that blacks are
overrepresented in low-income groups and whites are overrepresented
in high-income groups. Perhaps a history of racial discrimination in
this country has really systematically placed group in different levels
of socioeconomic status.'

-Amani Nuru-Jeter

Knowing how competitive it was to get into medical
school, she worried that her grades were not good
enough and asked herself, "what about Amani
is going to stand out?" She had attended a lot
of medicine-related conferences as an undergraduate
and noticed that many of the speakers had MD/MPH
next to their names, indicating a joint master's
degree in medicine and public health.

"I was like, what's 'public health'?" she
laughs. "Then I figured that if most MDs have
MPHs — you know, based on my small sample size — I
might as well get mine now and apply to medical school
afterward, thinking that will make me a more competitive
applicant."

Not wanting to leave the Washington area, she applied
to the only MPH program in D.C., George Washington
University's. In order to pay for the program, which
was geared to working people, she took a paid internship
at D.C.'s Department of Health, working full time
in the primary care office. It turned out to be the perfect match:
Nuru-Jeter found herself on the front lines of public
health policy as she studied its history by day
and its underpinnings at night.

Black and white terms

Working with both the city's public and
nonprofit health clinics, she was called on to
help investigate, for example, why people who were
eligible for Medicaid were not enrolled or falling
through the cracks of the health-care net in other
ways. After helping with a full-scale needs assessment
of the primary-care system in D.C., Nuru-Jeter began
working on J-1 visa waiver applications that would
bring qualified doctors from outside the United States
to work in underserved urban areas for a two-year
term.

This potent combination of classroom and fieldwork "totally
transformed my focus from wanting to deliver one-on-one
patient care, to wanting to be in a position to inform
policy that would affect populations of people at
a time," Nuru-Jeter says. Choosing her words
carefully, she explains that she was partly motivated
by the fact that when she sat at the table with the
Washington, D.C. city council and the heads of agencies
to discuss, for example, how best to create and fund
a children's health insurance program, she was dismayed
to realize that the people forming these policies
and determining where the money would go were not
only untrained in public health, but "were making
a lot of unfounded assumptions about what these communities
look like, and forming policies based on not a whole
lot of information."

Nuru-Jeter was, as she and others in her work life
saw it, "just a student,
and more often than not — if not always — the
only person of color, or the only woman of color,
at these tables where local public health policy
was literally being formed." She was
not confident enough to point out to the bigwigs
that sometimes they were "grossly misrepresenting" the
population that they were trying to serve. She decided
that the only way she would have a real voice in
such discussions was to go get another credential.
After finishing her M.P.H. in maternal and child
health at George Washington — the children's
health insurance program she had worked on became
the subject of her master's thesis — she went
for a Ph.D. in health policy and management at Johns
Hopkins Bloomberg School of Public Health, finishing
in May 2003.

Her dissertation looked at the roles of racial residential
segregation and concentrated poverty by race in the
relationship between income inequality and mortality.
She found that for an African-American person, living
in a primarily all-black community as opposed to
a more diverse one tended to have a negative effect
on their health. The opposite was true for whites.

But, I ask, referring back to income as a predictor
of health, "Isn't
an all-white community more likely to be a gated
suburb for rich people, versus an all-black area,
which has a greater chance of being urban and low
income?"

Nuru-Jeter
gently reminds me that such an assumption is an example
of unconscious bias, where "all white" assumes "positive
socioeconomic status" and "all black," the
opposite.Such assumptions aside, "all-black
middle-class and upper-middle-class metropolitan
areas do exist, and I studied those as well," she
answers. And the African-Americans living in those
communities still had poorer health than
their middle-class white counterparts. "There
was enough to suggest that there was an independent
relationship, that race and socioeconomic
status interact with one another in ways we don't yet
understand."

Quantifying the experience
of racism

After finishing her dissertation, Nuru-Jeter came
to Berkeley as a Robert Wood Johnson Health & Society
Scholar, in a two-year position similar to a postdoctoral
fellowship. The Robert Wood Johnson Foundation sponsors
a national program intended to build up the field
of population health, which looks at why some groups
of people are healthy and others are not. When the
fellowship ended, she decided to stay at UC Berkeley,
joining the faculty in 2005.

This semester, she's teaching social epidemiology,
which looks at how social and psychological factors
affect the distribution of disease in populations,
to graduate students. She loves teaching the class. "I
encourage my students to be scholars, not researchers.
Not to be data driven, but theory driven — to
ask the tough questions and then go find the data
that can test your idea," she says.

That's the only way to change how public health
research and practice happens, she contends. Ten
years ago, few schools of public health even offered
classes on racism. There is still some resistance
to studying the social determinants of health. Nuru-Jeter
says she often makes the mistake of thinking that
everyone thinks like her, that social
risk factors matter in and of
themselves, rather than because they muddle the other
relationships being looked at. "If
people like me continue to remove ourselves and stay
out of these circles, we're not going to be able
to change policy, school curricula, or anything else," she
says. "My hope, and I think that of the Robert
Wood Johnson Scholars Program, is to gain access
to these different environments where we can influence
the research questions that get asked, and where
we can be part of fostering a new generation of scholars
who will also challenge
our thinking about population health and health inequalities."

Nuru-Jeter is working on developing a tool with
which she hopes to answer that question of whether
racism, as part of the lived and social experience
of race, is at least partly to blame for African-Americans'
comparatively poorer health. Through
an interdisciplinary project based out of the Center
on Social Disparities and Health at UC San Francisco,
she has helped conduct multiple focus groups of
black women all across the Bay Area in which the
women were asked about their experiences of racism
at different life stages. She hopes to correlate
these experiences to actual birth outcomes. Relying
on the resulting 50-page transcripts of these free-ranging
conversations, she and the other researchers will
also attempt to identify recurring words and phrases
that can be used to build a survey of racism,
with funding from the Centers for Disease Control
and the Robert Wood Johnson Foundation.

The problem with current surveys, she says, is that
their questions ask, for example, whether the respondent
has experienced unfair treatment because of their
race in any one of these settings: work, housing,
etc. "What
we've found in our work is that yes, it's getting
housing, it's interfacing with the police system,
it's applying for jobs, and on and on and on —
these women talked about having discriminatory experiences
in every single area you can imagine," Nuru-Jeter
says. "So perhaps instead of having a list with
five domains, we need to figure out how to capture
the chronic and pervasive nature of racism that affects
women across every area of their life, not just the
few that seem to be most obvious. What we need to
know is how to quantify experiences they may have
had during pregnancy and during other life stages."

Nuru-Jeter is also working on a study to examine
the role of racial discrimination plays in racial
differences in other measures of biological stress
like "allostatic
load," a
composite of blood pressure, waist-hip ratio, and
other critical biomarkers. Although allostatic load
does have its detractors, she says, it is gaining
traction as a measure of the wear and tear that chronic
stress exacts on the body.

"The
hypothesis is that there is some type of mind-body
process, a psychophysiology associated with one's
social experience in the world, that is translated
and gets into the body to affect health outcomes.
When a person experiences an environmental assault,
or any kind of assault, there is a stress response:
your insulin, adrenaline, and epinephrine levels
go up," she explains, adding that the human
body has an internal mechanism that returns these
levels to stable after a period of time … usually. "The
idea behind allostatic load, however, is that perhaps
repeated assaults don’t allow the body to regain
its balance properly."

As a former English major struggling with the science
that Nuru-Jeter is cheerfully zooming through, I
present a hypothetical example. Say an African-American
woman has experienced discriminatory treatment a
few times at the hands of police officers, and each
instance has exacted a physiological toll.
Will her pulse race and her breathing quicken every
future time she sees a cop? Seems reasonable to me.
But is it this kind of constant exposure to a heightened
level of stress that might account for higher rates
of poor health?

Ever the careful researcher, Nuru-Jeter will not
bite. "Right now, we're just taking the first
step toward understanding the process," she
says. "But
what we do know is that it is more than just saying
that 'race matters' or 'socioeconomic status matters.'
The questions for me are, How does race
matter, how does socioeconomic status matter, and
how do the two matter together?"